MedNet Interface (MNI) - PatientOverview Composition - MedNet interface implementation guide v0.16.0

Reference(MedNet Interface (MNI) - Patient)

Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

subject

SΣ

1..1

Link to the Patient

encounter

SΣ

0..1

Reference(MedNet Interface (MNI) - Encounter)

An encounter will provide information about the context in which the form will be filled It is mainly used to deliver MedNet the Visit Nr (or Case Nr), and/or the orderNr from the calling System. The goal of those values is to allow saving the copy of the form and/or the later resulting report in the calling system to an internal event. It can also include informations about the priority of the request (if it is urgent or not), or the type of form that should be filled.

date

SΣ

1..1

dateTime

Composition editing time

Reference(MedNet Interface (MNI) - Device | MedNet Interface (MNI) - SoftwareUser)

SΣ

1..*

Who and/or what authored the composition

SΣ

1..1

Human Readable name/title
Fixed Value: PatientOverview

confidentiality

SΣ

1..1

N = normal
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

Fixed Value: N

attester

0..*

Attests to accuracy of composition

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

time

0..1

dateTime

When the composition was attested

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Who attested the composition

custodian

0..1

Reference(Organization)

Organization which maintains the composition

relatesTo

0..*

Relationships to other compositions/documents

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

target[x]

1..1

Target of the relationship

targetIdentifier

Identifier

targetReference

Reference(Composition)

event

0..*

The clinical service(s) being documented

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

0..*

Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.

period

0..1

Period

The period covered by the documentation

detail

0..*

The event(s) being documented

Slices for section

0..*

Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

section:All Slices

Content/Rules for all slices

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

0..1

Label for section (e.g. for ToC)

0..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

entry

0..*

A reference to data that supports this section

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:insuranceData

0..1

This section will provide patient insurance information
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Insurance data section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 76437-3

1..1

Representation defined by the system
Fixed Value: Primary insurance

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Coverage) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:Coverage

1..*

The coverage objects that will include all the informations about the insurances and invoices management

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionMedications

Nested Section

0..1

This section will provide all the Medication taken by the patient
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Medication Summary section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 10160-0

1..1

Representation defined by the system
Fixed Value: History of Medication use Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

entry:medicationStatement

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

1..*

Reference(MedNet Interface (MNI) - Medication Statement) {b }

A record of a medication that is being consumed by a patient

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionAllergies

0..1

This section will provide detailed information about allergies or intolerances of the patient (generally: Risk of adverse reaction to a substance)
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Allergies section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 48765-2

1..1

Representation defined by the system
Fixed Value: Allergies and adverse reactions Document

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

entry:allergyOrIntolerance

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

1..*

Reference(MedNet Interface (MNI) - Allergy Intolerance) {b }

An allergy or intolerance record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionProblems

0..1

This section will provide detailed information about conditions, problems or diagnoses (German = Diagnose, French = Diagnostics)
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Problems section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 11450-4

1..1

Representation defined by the system
Fixed Value: Problem list - Reported

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Condition) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:problem

1..*

A problem record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionProceduresHx

Nested Section

0..1

This section will provide detailed information about actions that are or were performed on or for a patient. This can be physical interventions like an operations, or less invasive like long term services, counseling, or hypnotherapy. (German = Massnahme, French = Intervention)
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Procedures section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 47519-4

1..1

Representation defined by the system
Fixed Value: History of Procedures Document

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Procedure) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:procedure

1..*

A procedure record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionResults

0..1